Constipation
| ICD9 = | ICDO = | Image = | Caption = | OMIM = | MedlinePlus = 003125 | eMedicineSubj = med | eMedicineTopic = 2833 | DiseasesDB = 3080 | }} This is a background article. See Constipation or irregularity, is a condition of the digestive system where a person (or animal) experiences hard feces that are difficult to eliminate; it may be extremely painful, and in severe cases (fecal impaction) lead to symptoms of bowel obstruction. Obstipation refers to severe constipation. Causes of constipation may be dietary, hormonal, a side effect of medications, an illness or disorder, and anatomical. Treatment is with a change in dietary and exercise habits. Signs and symptoms indicate constipation]] In common constipation, the stool is hard and difficult to pass. Usually, there is an infrequent urge to void. Straining to pass stool may cause hemorrhoids and anal fissures. In later stages of constipation, the abdomen may become distended and diffusely tender and crampy, occasionally with enhanced borborygmus {bowel sounds}. While many feel that one should have a bowel movement every day, some people may only feel the need to defecate one to three times a week. Medical authorities seem to accept wide variations in toilet frequency as long as this does not cause any other symptoms. Defecating depends on dietary habits, exercise, fluid intake, and various other factors. Severe cases ("fecal impaction") may feature symptoms of bowel obstruction (vomiting, very tender abdomen) and "paradoxical diarrhea", where soft stool from the small intestine bypasses the impacted matter in the colon. Constipation in children can lead to soiling (enuresis and encopresis). Diagnosis The diagnosis of constipation is essentially made from the patient's description of the symptoms. Bowel movements that are difficult to pass, very firm, or made up of small rabbit-like pellets qualify as constipation, even if they occur every day. Other symptoms related to constipation can include bloating, distention, abdominal pain, or a sense of incomplete emptying. Inquiring about dietary habits may reveal a low intake of dietary fiber or inadequate amounts of fluids. Constipation as a result of poor ambulation or immobility should be considered in the elderly. Constipation may arise as a side effect of medications (especially antidepressants and opiates). Rarely, other symptoms suggestive of hypothyroidism may be elicited. During physical examination, scybala (manually palpable lumps of stool) may be detected when a diagnostician presses on the abdomen. Rectal examination gives an impression of the anal sphincter tone and whether the lower rectum contains any feces or not; if so, then suppositories or enemas may be considered. Otherwise, oral medication may be required. Rectal examination also gives information on the consistency of the stool, presence of hemorrhoids, and whether any tumors or abnormalities are present. X-rays of the abdomen, generally only performed on hospitalized patients, may reveal impacted fecal matter in the colon, and confirm or rule out other causes of similar symptoms. Chronic constipation (symptoms present for more than 3 months at least 3 days per month) associated with abdominal discomfort is often diagnosed as irritable bowel syndrome (IBS) when no obvious cause is found. Physicians caring for patients with chronic constipation are advised to rule out obvious causes through normal testing.Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology 2006;130:1480–1491. PMID 16678561. Causes The main causes of constipation include: *Hardening of the feces ** Insufficient intake of dietary fiber ** Dehydration ** Medication, e.g. diuretics and those containing iron, calcium, aluminium *Paralysis or slowed transit, where peristaltic action is diminished or absent, so that feces are not moved along ** Hypothyroidism (slow-acting thyroid gland) ** Hypokalemia ** Injured anal sphincter (patulous anus) ** Medications, such as loperamide, opioids (e.g. codeine & morphine) and certain antidepressants ** Severe illness due to other causes; occasionally colds or flu ** Acute porphyria (a very rare inherited condition) ** Lead poisoning *Dyschezia syn(usually the result of suppressing defecation) *Constriction, where part of the intestine or rectum is narrowed or blocked, not allowing feces to pass ** Strictures ** Diverticula ** Tumors, either of the bowel or surrounding tissues ** Retained foreign body *Psychosomatic constipation, based on anxiety or unfamiliarity with surroundings. ** Functional constipation ** Constipation-predominant irritable bowel syndrome, characterized by a combination of constipation and abdominal discomfort and/or painCaldarella MP, Milano A, Laterza F, Sacco F, Balatsinou C, Lapenna D, Pierdomenico SD, Cuccurullo F, Neri M. Visceral sensitivity and symptoms in patients with constipation- or diarrhea-predominant irritable bowel syndrome (IBS): effect of a low-fat intraduodenal infusion. Am J Gastroenterol 2005;100:383-9. PMID 15667496. Treatment In people without medical problems, the main intervention is the increase of fluids (preferably water) and dietary fiber. The latter may be achieved by consuming more vegetables and fruit, whole meal bread and by adding linseeds to one's diet. The routine non-medical use of laxatives is to be discouraged as this may result in bowel action becoming dependent upon their use. Enemas can be used to provide a form of mechanical stimulation. Laxatives may be necessary in people in whom dietary intervention is not effective or is inappropriate. Stimulant laxatives (e.g. senna) are generally avoided, as they may worsen crampy sensations commonly experienced in constipation. In various conditions (such as the use of codeine or morphine), combinations of hydrating (e.g. lactulose or glycols), bulk-forming (e.g. psyllium) and stimulant agents may be necessary. Many of the products are widely available over-the-counter. Enemas and clysters are a remedy occasionally used for hospitalized patients in whom the constipation has proven to be severe, dangerous in other ways, or resistant to laxatives. Sorbitol, glycerin and arachis oil suppositories can be used. Severe cases may require phosphate solutions introduced as enemas. Constipation that resists all the above measures requires physical intervention. Manual disimpaction (the physical removal of impacted stool) is done by patients who have lost control bowels secondary to spinal injuries. Manual disimpaction is also a used by physicians and nurses to relieve rectal impactions. Finally, manual disimpaction can occasionally be done under sedation or a general anesthetic—this avoids pain and loosens the anal sphincter. In alternative and traditional medicine, colonic irrigation, enemas, exercise, diet and herbs are used to treat constipation. Constipation is usually easier to prevent than to treat. The relief of constipation with osmotic agents, i.e. lactulose, Polyethyleneglycol(PEG), or magnesium salts, should immediately be followed with prevention using increased fiber(fruits and vegetables) and a nightly decreasing dose of osmotic laxative. With continuing narcotic use, for instance, nightly doses of osmotic agents can be given indefinitely (without harm) to cause a daily bowel movement. Recent controlled studies have questioned the role of physical exercise in the prevention and management of chronic constipation, while exercise is often recommended by published materials on the subject. 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Chronic functional constipation in adolescents: Clinical findings and motility studies: Journal of Adolescent Health Vol 34(6) Jun 2004, 517-522. External links * * Category:Colon disorders Feces Category:Psychosomatic medicine